Citation NR: 9621660
Decision Date: 08/06/96 Archive Date: 08/15/96
DOCKET NO. 94-28 692 ) DATE
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On appeal from the
Department of Veterans Affairs Regional Office in St.
Petersburg, Florida
THE ISSUE
Entitlement to service connection for bullous keratoplasty
with cataract extraction, left eye, as secondary to a
service-connected corneal scar of the left eye, traumatic.
REPRESENTATION
Appellant represented by: Disabled American Veterans
WITNESS AT HEARING ON APPEAL
Appellant
ATTORNEY FOR THE BOARD
P. M. Lynch, Associate Counsel
INTRODUCTION
The veteran’s active military service extended from December
1940 to May 1945.
This matter comes before the Board of Veterans’ Appeals
(Board) on appeal from a February 1992 rating decision by the
Department of Veterans Affairs (VA) Regional Office (RO) in
St. Petersburg, Florida, that denied the veteran’s claim of
entitlement to service connection for bullous keratoplasty
with cataract extraction and lens implant, left eye, status
post cystoid macular edema with hyperopia and presbyopia.
CONTENTIONS OF APPELLANT ON APPEAL
In pursuing his appeal to the Board on the claim for service
connection for an eye disorder, the veteran, in essence,
contends that the RO committed error in denying that claim.
He maintains that his current left eye disability was caused
by his service-connected left corneal scar.
DECISION OF THE BOARD
The Board, in accordance with the provisions of 38 U.S.C.A.
§ 7104 (West 1991 & Supp. 1995), has reviewed and considered
all of the evidence and material of record in the veteran’s
claims file. Based on its review of the relevant evidence in
this matter, and for the following reasons and bases, it is
the decision of the Board that the evidence supports
entitlement to service connection for bullous keratoplasty
with cataract extraction, left eye, as secondary to a
service-connected corneal scar of the left eye, traumatic.
FINDINGS OF FACT
1. The RO has obtained all relevant evidence necessary for
an equitable disposition of the veteran’s appeal.
2. The veteran sustained a left eye injury, diagnosed as
“foreign body, intraocular, left eye ball, traumatic,” during
active service in 1944. Service connection was granted for
this disability in May 1945.
3. As a result of the service-connected eye disability, the
veteran experienced a foreign body sensation in his left eye
and was prescribed a contact lens to alleviate these
symptoms.
4. In approximately 1985, the veteran was diagnosed as
having bullous keratoplasty of the left eye. He underwent
penetrating keratoplasty and extracapsular cataract
extraction with an intraocular lens implant in 1987.
5. In November 1993, a VA ophthalmologist concluded that the
veteran’s current eye disorder was probably due to wearing a
contact lens for an extended period of time.
CONCLUSION OF LAW
Bullous keratoplasty with cataract extraction, left eye, is
proximately due to or the result of a service-connected
injury. 38 C.F.R. § 3.310(a) (1995).
REASONS AND BASES FOR FINDINGS AND CONCLUSION
The veteran’s claim is “well grounded” within the meaning of
38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1995). That is, he
has presented a claim which is plausible. All relevant facts
have been properly developed and no further assistance to the
veteran is required to comply with the duty to assist
mandated by 38 U.S.C.A. § 5107(a).
Service connection may be established for disability that is
proximately due to or the result of a service-connected
disease or injury. 38 C.F.R. § 3.310(a) (1995).
Establishing service connection on such a “secondary” basis
requires evidence sufficient to show (1) that a current
disability exists and (2) that the current disability was
either (a) caused by or (b) aggravated by a service-connected
disability. 38 C.F.R. § 3.310(a) (1995); Allen v. Brown,
7 Vet.App. 439 (1995) (en banc), reconciling, Leopoldo v.
Brown, 4 Vet.App. 216 (1993), and Tobin v. Derwinski, 2
Vet.App. 34 (1991).
Here, the veteran’s service medical records show that in 1944
he sustained an injury to his left eye. He was diagnosed as
having “foreign body, intraocular, left eye ball, traumatic.”
On discharge examination in December 1944, the examiner noted
the presence of a left corneal scar.
By a rating decision in May 1945, the RO granted the veteran
entitlement to service connection for a foreign body in the
left eye ball.
The veteran was afforded a VA eye examination in September
1947. The examiner diagnosed corneal scar of the left eye
due to trauma from combat. The examiner further noted that
there was no evidence of an intraocular foreign body at that
time.
By a rating decision in November 1947, the RO recharacterized
the veteran’s disability as a corneal scar.
Private medical records from Michael P. Pennachio, M.D. dated
in August 1985 reveal that the veteran sought treatment for
left eye symptomatology. In recording the veteran’s history,
Dr. Pennachio noted that he had a shrapnel injury to his left
eye 40 years earlier and that due to a continuous foreign
body sensation, he had been fitted with a contact lens.
Pertinent diagnoses included old traumatic corneal injury
with bullous changes inferiorly, traumatic bullous
keratopathy and contact lens intolerance with possible staph.
blepharoconjunctivitis.
In August 1987, the veteran underwent penetrating
keratoplasty and extracapsular cataract extraction with an
intraocular lens implant at the VA Medical Center in
Gainesville, Florida.
The RO obtained an opinion from a VA ophthalmologist in
November 1993 regarding the etiology of the veteran’s current
eye disability. The VA examiner concluded that the veteran’s
bullous keratopathy and bullous changes of the left inferior
cornea were not directly related to the eye injury that
occurred during service. However, the examiner did find that
the current eye disability was probably due to the possible
staph. keratoconjunctivitis and due to wearing a contact lens
for an extended period of time.
The Board notes that the veteran testified in October 1993
that Dr. Pennachio fitted him with a contact lens in his left
eye to alleviate symptomatology associated with his corneal
scarring. As noted above, Dr. Pennachio’s treatment notes do
show that the veteran was fitted with a contact lens due to a
foreign body sensation in the left eye; although it is not
clear who prescribed this treatment.
Upon consideration of the veteran’s sworn testimony to the
effect that the contact lens was prescribed as treatment for
his service-connected left eye symptomatology, as supported
by Dr. Pennachio’s treatment notes, and coupled with the
objective medical evidence of record showing that the current
eye disability was related to the wearing of the contact
lens, the Board believes that the record supports entitlement
to service connection for the current eye disability on a
secondary basis. 38 C.F.R. § 3.310(a) (1995).
ORDER
Entitlement to service connection for bullous keratoplasty
with cataract extraction, left eye, as secondary to a
service-connected corneal scar of the left eye, traumatic, is
granted.
KENNETH R. ANDREWS. JR.
Member, Board of Veterans’ Appeals
The Board of Veterans’ Appeals Administrative Procedures
Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 741
(1994), permits a proceeding instituted before the Board to
be assigned to an individual member of the Board for a
determination. This proceeding has been assigned to an
individual member of the Board.
NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West
1991 & Supp. 1995), a decision of the Board of Veterans’
Appeals granting less than the complete benefit, or benefits,
sought on appeal is appealable to the United States Court of
Veterans Appeals within 120 days from the date of mailing of
notice of the decision, provided that a Notice of
Disagreement concerning an issue which was before the Board
was filed with the agency of original jurisdiction on or
after November 18, 1988. Veterans’ Judicial Review Act,
Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The
date which appears on the face of this decision constitutes
the date of mailing and the copy of this decision which you
have received is your notice of the action taken on your
appeal by the Board of Veterans’ Appeals.
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